Elyn R. Saks The Center Cannot Hold: “The most lucid and hopeful memoir of living with schizophrenia I have ever read” (Oliver Sacks). But is it schizophrenia?

As stated on the front flap, “Elyn Saks is a success by any measure: She’s an endowed professor at the prestigious University of Southern California Gould School of Law. She has managed to achieve this in spite of being diagnosed as schizophrenic and given a ‘grave’ prognosis—and suffering the effects of her illness throughout her life.” The back flap adds that she is also an adjunct professor of psychiatry, a research clinical associate in psychoanalysis, and married. The flaps and back cover also include praise of the book from five eminent psychiatrists.

With all that consensus, if I question the diagnosis, I’ve probably misread the book, don’t you think? However, I’m interested in the distinction between schizophrenia and multiple personality, so here I go again.

The strong case in favor of her diagnosis of schizophrenia is that, for many years, she has had major episodes of, and continual tendencies toward, delusions (e.g., that she has killed many people with her thoughts), plus a lot of crazy, disjointed, nonsensical talk. Moreover, when she finally started taking antipsychotic medication (including Navane, then Zyprexa, and eventually clozapine) her psychotic symptoms were much less—often gone or minimal—but would relapse when she went off the medication.

Both Psychotic and Cogent

My first quibble with the diagnosis is that I don’t see how a person with schizophrenia can be flagrantly illogical and delusional during the same period of time in her life that she produces an excellent, fifty page, legal article (unless Hyde was the crazy one, and Jekyll wrote the article):

“In one [psychotherapy] session with [a psychologist-psychoanalyst], I was frantically pacing from one side of his office to the other, growing more agitated as my thoughts became more violent. ‘I’ve killed people and I will kill again,’ I announced. I was almost growling at him. ‘Who else is in the office with us? Are you human?’ “ (1, p. 134).

Meanwhile, “In [law school], I was assigned to prepare my first legal memo. Its purpose was to explain a very specific area of law, in a succinct, cogent manner…the length was to be no more than fifteen pages…I worked on the memo day and night…And when I was finished, my paper was nearly fifty pages in length. I later learned that the person in charge of grading papers thought that it was one of the two best pieces of work turned in by anyone that year…something inside me pushed me farther than I was supposed to go…” (1, pp. 134-135).

Diagnostic Controversy

Over the years, Saks’s doctors have not always diagnosed schizophrenia. Some had previously said that she had depression or schizoaffective disorder or atypical psychosis. A history of disagreement about diagnosis and of changing a patient’s diagnosis is much more common in cases that are eventually revealed to be multiple personality than in cases of schizophrenia.

Clinically Atypical

In the psychotherapy session quoted above, Saks’s disconnected thoughts could be called “loose associations,” a supposedly classic symptom of schizophrenia, but they strike me as inauthentic; not faked—there is no reason for her to fake—but not the way I have ever heard any of my own schizophrenic patients talk.

(However, if Saks was not quoting therapy transcripts, but only recreating what had been said, perhaps what I find inauthentic is only her retrospective version of what she had said.)

Suggestive of Multiple Personality

Saks occasionally says and does things that people unfamiliar with multiple personalty might take as evidence of schizophrenia, but which might not be. For example, she says, “I started to sense that the others—the beings who never seemed far off when I got sick—were in the office with me. An evil presence, and growing stronger. Why are they here? Are they trying to take over my mind? Why do they want to hurt me?” (1, p. 249). This could be schizophrenic delusion, but it could also be the host personality’s experience of rival alternate personalities who want to get her out of the way by getting her hospitalized.

That is how Dostoevsky’s The Double ended, with the regular personality carted off to the mental hospital while the alternate personality took his place in everyday life. Alternate personalities have such a sense of their separate existence that they sometimes even think that they can kill the host personality while they themselves remain alive.

“Another command (or thought, or message) I continually received was to hurt myself…So I burned myself—with cigarettes, lighters (easily come by…) electric heaters, boiling water. I burned my flesh in places on my body that I thought people would never see…” (1, p. 85). I previously discussed self-mutilation caused by persecutor personalities (search posts) in my post on Gillian Flynn’s novel Sharp Objects.

Saks says that one of her doctors “didn’t want me to cover my face with my hands during our sessions, something I’d done with all my analysts to help me feel safe and contained” (1, p. 322). As I discussed in a previous post about Charlotte Brontë—who was described as repeatedly seen to turn her face away from the person she was speaking to at school before she suddenly changed from reticent to talkative—people with multiple personality may want to hide the switch from one personality to another, which they think will be detected if their face is seen at the moment of the switch. It sounds to me like Saks was hiding her personality switches during therapy sessions.

Schizophrenia or Multiple Personality

Saks, who once wrote a book on the law and multiple personality, is familiar with it, and in interviews, she always emphasizes that she has schizophrenia, not multiple personality. And since her memoir has nothing definitive in regard to multiple personality, she may be right.

Her positive response to medication does not necessarily prove that she has schizophrenia. The medicine may help by shifting the balance of power among her personalities, making it harder for problematic alternate personalities to take over. I learned about this possibility when the host personality of a patient of mine with multiple personality would “misplace” her antidepressant medicine from time to time. Her alternate personality later admitted to me that she would hide the medicine, because when the host took it, it would be harder for the alternate personality to come out.

So is Saks a very high-achieving person with schizophrenia or a very high-achieving person with undiagnosed multiple personality? I am undecided.

1. Elyn R. Saks. The Center Cannot Hold: My Journey Through Madness. New York, Hyperion, 2007.